Dear Ms Mutch

Wendy Margaret Wilkes - Regulation 28 Report to Prevent Future Deaths

Further to your letter, dated 20 April 2020, regarding the tragic case of Wendy Margaret Wilkes please find my response outlined below.

The untimely death of a person is distressing for their family and any others affected by their death and loss, and all the more so if there is any belief that but for the actions of any organisation it could have been avoided.

I would like to record my sincere condolences to the family of Wendy Margaret Wilkes for their loss and I hope through this process they can obtain some closure.

Your report highlights concerns raised with the Regulation 28 Report to Prevent Future Deaths were as follows;

 No clear system of alert notes/follow up review appointments at her GP practice despite the extent of the prescribed medication; and

 The General Practitioners’ Practice (“Practice”) did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the prescribed medication.

The Haughton Thornley Medical Centres have undertaken a Significant Event Analysis of the circumstances, which was subject to a Clinical Peer Group discussion of all General Practitioners Haughton Thornley Medical Centres at a GP meeting on 25 February 2020.

Significant Event Analyses are reflective tools that take place in all healthcare settings when there has been a significant event. They allow clinicians to review what has happened, understand what learning can be taken from the incident to prevent it happening in the future, sharing best practice and making sure that the recommended learning and the subsequent changes are put in place.

As a result of the findings of the Significant Event Analysis, the practice has put in place several safeguarding changes from 25 February 2020.

Strictly Private and Confidential

Alison Mutch OBE HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG

CHIEF EXECUTIVE

Steven Pleasant MBE Chief Executive, Tameside MBC and Accountable Officer, Tameside & Glossop CCG Tameside One, Market Place, Ashton under Lyne, OL6 6BH

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Call Centre 0161 342 8355

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Date 15 June 2020

Enc: General Practitioners Guidance document regarding patients taking opioids and neuropathic drugs with alcohol dependency (June 2020)

Alert Note/Review System effective from 25 February 2020 The practice has identified relevant existing patients by running reports for patients coded on the practice’s clinical system as using neuropathic medication, cross referenced with patients coded with alcohol dependency who have had an intentional or accidental overdose. A “flag” is now placed on these patients’ medical records and a medication review is undertaken. The patients are then contacted to discuss their medication and their alcohol consumption.

This process is managed by the Practice Manager who will run this report every three months to ensure it is constantly identifying the cohort of patients. The process will be reviewed at these three monthly intervals and will evolve from any learning taken from them.

The process for patients who may unfortunately suffer from an intentional/accidental overdose in the future when the practice has been made aware of an overdose, is that the patient will be seen and reviewed by the Practice. Subsequently, in order to minimize the risks of future overdoses, all such patients will be placed on weekly prescriptions. The practice will refer patients to mental health services, social prescribing and drug and alcohol service as appropriate.

To further support this process, non-clinical staff have been trained to ensure that information related to intentional or accidental overdoses are shared with the General Practitioners in the practice; so the process described above can be followed.

Tameside and Glossop Clinical Commissioning Group (CCG) actions , Director of Commissioning, is accountable to ensure that in line with the Coroner’s request, the following actions will be undertaken:

The CCG has developed the enclosed guidance to all practices regarding the identification and management of patients prescribed neuropathic drugs and opioids that may also be dependent upon alcohol to ensure they are safely managed. This has been sent to all practices electronically to be shared internally at their clinical meetings and for them to save on their electronic systems (June 2020)

We shall keep these issues under review as part of the quality monitoring reported to the Strategic Commissioning Board, whose meetings are held in public. Minutes are available on the Tameside and Glossop CCG website (https://www.tamesideandglossopccg.org/corporate/strategic- commissioning-board).

The quality of care in primary care is also discussed and reviewed at the following monthly meetings: Primary Care Delivery and Improvement Group and Primary Care Committee.

I trust that our actions offer reassurance that the CCG and the Practice have reflected on the evidence and findings provided at Mrs Wilkes’ Inquest. It is acknowledged that there has been a great deal of learning and reflection following the Inquest of Mrs Wilkes and we assure you that this learning has been shared and disseminated.

I hope this brings some reassurance that we are working to ensure another tragic loss of life doesn’t occur in similar circumstances.

Please contact me if you require any further information or if I can assist further in any way.

Dear Ms Mutch

Re: Regulation 28 Report to Prevent Future Deaths – Wendy Margaret Wilkes 06/08/19

Thank you for your Regulation 28 Report dated 21 April 2020 concerning the death of Wendy Margaret Wilkes on 06 August 2019. I am sending this reply by email to the above address as discussed and agreed by my PA and your office today.

Firstly, I would like to express my deep condolences to Wendy Margaret Wilkes’ family.

The inquest concluded that Wendy Margaret Wilkes’ death was a result of 1a) ethanol toxicity on a background of concomitant use of gabapentin, zopiclone, diazepman and amitryptiline; II) Alcohol related fatty liver disease.

Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding that there was no clear system of alert notes/follow up review appointments at her GP practice despite the extent of the prescribed medication; The GP practice did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the prescribed medication.

I have noted that your Regulation 28 letter has also been sent to the Clinical Commissioning Group concerned and I will leave it to the named respondent to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP.

Summary of actions taken or being taken by the organisation involved.

The CCG will ensure that;

1. Practices will undertake a search on a quarterly basis for patients coded as taking opioids or neuropathic drugs cross referenced with alcohol dependency so that they can understand their existing cohort of at risk patients, place a flag on their record, review their medication and contact them to discuss their medication and their consumption of alcohol.

2. When a practice becomes aware of any patient who has overdosed, whether accidentally or intentionally, a flag should be placed on their records, their medication will be reviewed and a discussion be had with the patient about their medication and their alcohol consumption. Place the patient on weekly prescriptions to reduce the possibility of any further harm if it is deemed clinically appropriate after a discussion with the patient.

Actions taken or being taken to prevent reoccurrence across Greater Manchester.

1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.

2. Learning to be shared with the Greater Manchester commissioners of services to assure themselves of the quality of services they commission.

3. An alert will be issued to all GP practices to ensure that they have clear systems of alert notes/follow up review appointments for individuals with extensive prescribed medications. The alert also requests GP practices consider how their systems can alert prescribers to patients with high alcohol usage when prescribing medications to ensure effective risk assessments can be carried out.

Previously, across Greater Manchester, a set of nine standards were developed to improve quality and reduce unwarranted variation in the delivery of primary care. The standards were first developed in 2014 and a refreshed version implemented in
2018.

The system remains committed to ensuring that Standard 7 – embedding a culture of safety – which aims to make Greater Manchester the safest, most effective place to receive medicines and treatments is achieved. It aims to improve reporting rates of medicine related safety incidents, improve uptake of safety audit software and reduce medicine safety incidents over time. Specifically, this includes establishing

processes of shared learning / peer reviews within a practice and neighbourhood setting, including incident reporting, lessons learnt, embedding remedial actions and review processes. All 10 localities implemented this standard in full or in part and are committed to improving medication safety. Local examples of this include locally commissioned quality improvement programmes, closer working with CCG medicines management teams, inclusion of safety champions and medicines management peer reviews.

The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice.

I hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.